Knowledge Base Article

Q:

How is CMS responding to the Court ruling to immediately cease the clinic visit provided at excepted off-campus PBDs payment reduction for CY 2019?

A:

According to an announcement about Payment for Outpatient Clinic Visit Services at Excepted Off-Campus Provider-Based Departments in the December 12th edition of MLN Connects, “CMS installed a revised Hospital Outpatient Prospective Payment System Pricer to update the rates being applied to claim lines. The revised Pricer went into production on November 4, 2019, and applies to claims with a line item date of service of January 1, 2019, and after. Starting January 1, 2020, and over the next few months, the Medicare Administrative Contactors will automatically reprocess claims paid at the reduced rate; no provider action needed.”

In the 2019 OPPS Final Rule, CMS determined to pay for certain outpatient clinic visit services (HCPCS code G0463) provided at excepted off-campus Provider-Based Departments (PBDs) at the same rate that CMS uses to pay non-excepted off-campus PBDs for those services under the separate Physician Fee Schedule (PFS). The PFS payment rate for services in non-excepted off-campus PBDs is equal to 40% of the OPPS rate, a reduction of 60%. CMS phased in the payment reduction for clinic visits in excepted off-campus PBDs over 2 years, with a 30% reduction for 2019 (i.e. rates of 70% of OPPS rates) and the full 60% reduction planned for 2020.

Despite the court’s decision that CMS must pay 2019 clinic visits in excepted off-campus PBDs at the regular OPPS rate, CMS proceeded with the second year of the payment reduction in the 2020 OPPS Final Rule. See the prior Wednesday@One article for more information about this but here are some excerpts from that article:

“CMS claims they are ‘removing the payment differential that drives the site-of-service decision and, as a result, unnecessarily increases service volume.’ They further claim they are doing this under authority of a certain section of the Social Security Act that gives them power ‘to adopt a method to control unnecessary increases in the volume of covered outpatient department services.’ … CMS states they have appeal rights and are still considering whether to appeal the final judgement or not.”